Project Summary/Abstract Rapid social and environmental development in low and middle income countries (LMIC) has contributed to the increasing prevalence of obesity and cardiometabolic disease in children and adults. Changes in diet, however, have outpaced water and sanitation improvements, contributing to a dual burden of overweight/noncommunicable disease (OWT/NCD) and persistent undernutrition and infectious disease (UND/ID) within individuals and households. Disentangling the biological, social and environmental pathways leading to the dual burden of disease is particularly critical in LMIC, like Ecuador, where economic development has been rapid and accompanied by dramatic shifts in diet, disease burden and lifestyle. Yet, little work has examined the independent and joint impact of water and food access, quality and security on the development of OWT/NCD and UND/ID or how psychological distress (PD) associated with insecure access to clean water and market foods may mediate the dual burden at the household level. Our team will fill this gap. We will capitalize on secondary analysis of an existing dataset, the nationally-representative Encuensta National de Salud and Nutricion-Ecuador 2012 (Ensanut) and the existing partnership between the University of North Carolina at Chapel Hill and the Universidad San Francisco Quito (USFQ) on the Galapagos Islands to guide an exploratory, in-depth survey of 125 urban and rural households. We will incorporate biological, ecological, spatial, and survey data, to 1) examine the socioeconomic and development factors associated with household water access and diet quality, 2) test the pathways linking water and food access, quality, and security to the dual burden of OWT/NCD and UND/ID, and 3) examine whether PD mediates these pathways at the individual and household-levels. Our results will advance knowledge by: 1) describing the burden of disease in this model LMIC setting, 2) documenting the pathways linking water and food exposures to the dual burden and 3) showing how PD may contribute to UND/ID and OWT/NCD at the household-level, creating a triple burden of disease. The Galapagos Islands provide a unique opportunity to study the impact of the environmental and social changes facing LMICs impacted by migration, urbanization and shifting diet and disease burdens within a relatively closed ecosystem. Our secondary data analysis and primary data collection will inform an R01 that will scale up our novel measures (water security, water quality, and PD) to more widely examine the triple burden of disease in Ecuador. This R21 will capitalize upon an existing relationship between UNC and USFQ, build our collaborative research capacity, provide training in statistical and biomarker analysis to LMIC researchers, and improve the research infrastructure in Ecuador to permit the development of an expanded R01 project to address important health research needs and identify avenues for intervention.